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Takekuma M, Takahashi F, Mabuchi S, Kudaka W, Horie K, Ikeda M, Shikama A, Mitsuhashi A, Nagao S, Suzuki S, Mizuno M, Nishio S, Tokunaga H, Ota Y, Kasamatsu T, Kitagawa R, Toita T, Kobayashi H, Ishikawa M, Yaegashi N. Propensity score-matched analysis of systemic chemotherapy versus salvage hysterectomy for persistent cervical cancer after definitive radiotherapy/concurrent chemoradiotherapy. BMC Cancer 2020; 20:1169. [PMID: 33256667 PMCID: PMC7708164 DOI: 10.1186/s12885-020-07672-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 11/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of the current study was to evaluate oncologic outcomes of patients who were treated with salvage hysterectomy (HT), compared to systemic chemotherapy (CT) for persistent cervical cancer after definitive radiotherapy (RT)/ concurrent chemoradiotherapy (CCRT). METHODS Patients with persistent cervical cancer treated with definitive RT/CCRT at 35 institutions from 2005 to 2014 were reviewed retrospectively (n = 317). Those who underwent a HT for persistent cervical cancer after definitive RT/CCRT were matched with propensity scores for patients who underwent systemic CT. Oncologic outcomes between the two groups using a propensity score matched-cohort analysis were compared. RESULTS A total of 142 patients with persistent cervical cancer after definitive RT/CCRT were included after matching (HT: 71, systemic CT: 71). All background factors between HT and CT groups were well balanced. Median overall survival was 3.8 and 1.5 years in the HT and CT groups, respectively (p = 0.00193, hazards ratio [HR] 0.41, 95% confidence interval [CI] 0.23-0.73), Increasing residual tumor size was significantly associated with a high incomplete resection rate (p = 0.016, Odds Ratio 1.11, 95%CI 1.02-1.22). Severe late adverse events occurred in 7 patients (9.9%) in the HT cohort. CONCLUSION The current study demonstrated that, when compared to systemic CT, the adoption of salvage HT for patients with persistent cervical cancer after definitive RT/CCRT reduced mortality rate by about 60%. This indicates that salvage HT could be curative treatment for those patients. Further prospective clinical trials with regard to salvage HT after RT/CCRT are warranted.
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Affiliation(s)
- Munetaka Takekuma
- Department of Gynecology, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumicho, Suntogun, Shizuoka, 411-8777, Japan.
| | - Fumiaki Takahashi
- Department of Information Science, Iwate Medical University, Idaidori, Yahabacho, Shiwagun, Iwate, 028-3694, Japan
| | - Seiji Mabuchi
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 202 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Wataru Kudaka
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishiharacho, Nakagamigun, Okinawa, 903-0125, Japan
| | - Koji Horie
- Department of Gynecology, Saitama Cancer Center, 818 Komuro, Inamachi, Kitaadachigun, Saitama, 362-0806, Japan
| | - Mariko Ikeda
- Department of Gynecology, Kanagawa Cancer Center, Nakaonaga, Asahiku, Yokohama, Kanagawa, 241-0815, Japan
| | - Ayumi Shikama
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Akira Mitsuhashi
- Departments of Reproductive Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuoku, Chiba, Chiba, 260-8677, Japan
| | - Shoji Nagao
- Department of Gynecologic Cancer, Hyogo Cancer Center, 13-70 Kitaozicho, Akashi, Hyogo, 673-8558, Japan
| | - Shiro Suzuki
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showaku, Nagoya, Aichi, 466-8550, Japan
| | - Mika Mizuno
- Department of Gynecology, Aichi Cancer Center Hospital, Kanokoden, Chikusaku, Nagoya, Aichi, 464-8681, Japan
| | - Shin Nishio
- Department of Obstetrics and Gynecology, Kurume University School of Medicine, 67 Asahicho, Kurume, Fukuoka, 830-0011, Japan
| | - Hideki Tokunaga
- Department of Obstetrics and Gynecology, Tohoku University Hospital, Seiryo-machi, Aobaku, Sendai, Miyagi, 980-8574, Japan
| | - Yukinobu Ota
- Department of Gynecology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuoku, Osaka, Osaka, 541-8567, Japan
| | - Takahiro Kasamatsu
- Department of Obstetrics and Gynecology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumidaku, Tokyo, 130-8575, Japan
| | - Ryo Kitagawa
- Department of Gynecology and Obstetrics, Tohoku Medical and Pharmaceutical University, 4-4-1 Komatsushima, Aobaku, Sendai, Miyagi, 981-8558, Japan
| | - Takafumi Toita
- Radiation Therapy Center, Okinawa Chubu Hospital, 281 Aza-miyazato, Uruma, Okinawa, 904-2293, Japan
| | - Hiroaki Kobayashi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima, 890-8544, Japan
| | - Mitsuya Ishikawa
- Department of Gynecology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuoku, Tokyo, 104-0045, Japan
| | - Nobuo Yaegashi
- Department of Obstetrics and Gynecology, Tohoku University Hospital, Seiryo-machi, Aobaku, Sendai, Miyagi, 980-8574, Japan
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Li L, Ma SQ, Tan XJ, Zhong S, Wu M. Pelvic Exenteration for Recurrent and Persistent Cervical Cancer. Chin Med J (Engl) 2018; 131:1541-1548. [PMID: 29941707 PMCID: PMC6032675 DOI: 10.4103/0366-6999.235111] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Pelvic exenteration (PE) for primary and recurrent cervical cancer has resulted in favorable survival outcomes, but there are controversies about specific prognosis factors, and up to now, there have been no published reports from China. This study aimed to share our experiences of PE, which were performed in a single institution. Methods: From January 2009 to January 2016, 38 patients with recurrent or persistent cervical cancer were included in the study, and they were followed up until January 2017. Epidemiological and clinicopathological characteristics of patients were compared for survival outcomes in univariate and Cox hazard regression analysis. Results: There were thirty-one and seven patients with recurrent and persistent cervical cancer, respectively. The median age of patients was 45 years (range 29–65 years). Total, anterior, and posterior PE consisted of 52.6%, 28.9%, and 18.4% of cases, respectively. Early and late complications occurred in 21 (55.3%) patients and 15 (39.5%) patients, respectively. Two (5.3%) patients died due to complications related to surgeries within 3 months after PE. The median overall survival (OS) and disease-free survival (DFS) were 28.5 months (range 9–96 months) and 23 months (range 4–96 months), respectively, and 5-year OS and DFS were 48% and 40%, respectively. Cox hazard regression analysis showed that, the margin status of the incision and mesorectal lymph node status were independent risk factors for OS and DFS. Conclusion: In our patients with recurrent and persistent cervical cancer, the practice of PE might achieve favorable survival outcomes. Trial Registration: ClinicalTrials.gov, NCT03291275; https://clinicaltrials.gov/ct2/show/NCT03291275?term=NCT03291275&rank=1.
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Affiliation(s)
- Lei Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Shui-Qing Ma
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xian-Jie Tan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Sen Zhong
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Ming Wu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
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Sardain H, Lavoué V, Foucher F, Levêque J. [Curative pelvic exenteration for recurrent cervical carcinoma in the era of concurrent chemotherapy and radiation therapy. A systematic review]. ACTA ACUST UNITED AC 2016; 45:315-29. [PMID: 26874666 DOI: 10.1016/j.jgyn.2016.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 01/02/2016] [Accepted: 01/08/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The purpose of this review is to assess the preoperative management in case of recurrent cervical cancer, to assess patients for a surgical curative treatment. METHODS English publications were searched using PubMed and Cochrane Library. RESULTS In the purpose of curative surgery, pelvic exenteration required clear margins. Today, only half of pelvic exenteration procedures showed postoperative clear margins. Modern imaging (RMI and Pet-CT) does not allow defining local extension of microcopic disease, and thus postoperative clear margins. Despite the same generic term of pelvic exenteration, there is a wide heterogeneity in surgical procedures in published cohorts. CONCLUSION Because clear margins are required for curative pelvic exenteration, but are not predictable by preoperative assessment. The larger surgery, i.e. the infra-elevator exenteration with vulvectomy, could be the logical surgical choice to increase the rate of clear margins and therefore, recurrent cervical carcinoma patient survival.
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Affiliation(s)
- H Sardain
- Gynecology Department, Tertiary Surgery Center, Teaching Hospital of Rennes, hôpital Sud, CHU de Rennes, 16, boulevard de Bulgarie, 35000 Rennes, France; Faculty of Medicine, université de Rennes 1, 2, rue Henry-Guilloux, 35000 Rennes, France.
| | - V Lavoué
- Gynecology Department, Tertiary Surgery Center, Teaching Hospital of Rennes, hôpital Sud, CHU de Rennes, 16, boulevard de Bulgarie, 35000 Rennes, France
| | - F Foucher
- Gynecology Department, Tertiary Surgery Center, Teaching Hospital of Rennes, hôpital Sud, CHU de Rennes, 16, boulevard de Bulgarie, 35000 Rennes, France
| | - J Levêque
- Gynecology Department, Tertiary Surgery Center, Teaching Hospital of Rennes, hôpital Sud, CHU de Rennes, 16, boulevard de Bulgarie, 35000 Rennes, France; Faculty of Medicine, université de Rennes 1, 2, rue Henry-Guilloux, 35000 Rennes, France
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Curative pelvic exenteration for recurrent cervical carcinoma in the era of concurrent chemotherapy and radiation therapy. A systematic review. Eur J Surg Oncol 2015; 41:975-85. [DOI: 10.1016/j.ejso.2015.03.235] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 03/08/2015] [Accepted: 03/26/2015] [Indexed: 11/22/2022] Open
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Prognostic Factors for Curative Pelvic Exenterations in Patients With Recurrent Uterine Cervical or Vaginal Cancer. Int J Gynecol Cancer 2014; 24:1679-85. [DOI: 10.1097/igc.0000000000000288] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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Besson N, Touboul E, Daraï É, Lefranc JP, Monnier L, Schlienger M, Huguet F. [Isolated pelvic recurrences of cervical carcinoma treated with salvage chemoradiotherapy]. Cancer Radiother 2014; 18:83-8. [PMID: 24462252 DOI: 10.1016/j.canrad.2013.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 11/18/2013] [Accepted: 11/28/2013] [Indexed: 11/16/2022]
Abstract
PURPOSE Evaluation of the results of salvage radiation therapy with curative intent in the treatment of recurrent cervical carcinoma. PATIENTS AND METHODS Fourteen patients with a recurrence of a cervical cancer were treated in our department between 1982 and 2009. Five patients had a pelvic relapse, four a vaginal relapse and five a pelvic lymph node relapse. Four patients had first a surgical resection of the relapse, which was incomplete in two patients. All patients had pelvic radiotherapy with a median dose of 55Gy in conventional fractionation. Concurrent chemotherapy was administered to 12 patients. A vaginal brachytherapy with a median dose of 20Gy was performed in addition in 3 patients. The median follow-up was 39months. RESULTS Safety of radiation therapy was correct with 29% of grade 3 acute or intestinal toxicity. Tumor control was observed in 10 patients (71%). Four patients presented a locoregional tumor progression. At the time of analysis, three patients had died from their cancer. From the date of relapse, the rate of overall survival at 2 and 5year was respectively 84% and 74%. Three patients (21%) had severe late effects. CONCLUSION In our experience, chemoradiotherapy can achieve a high rate of remission in patients with isolated pelvic recurrence of cervical cancer. This treatment is feasible only if the patient had not received radiation therapy before or if the relapse is out of the previously irradiated volume.
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Affiliation(s)
- N Besson
- Service d'oncologie radiothérapie, hôpital Tenon, hôpitaux universitaires Est parisien, 4, rue de la Chine, 75020 Paris, France
| | - E Touboul
- Service d'oncologie radiothérapie, hôpital Tenon, hôpitaux universitaires Est parisien, 4, rue de la Chine, 75020 Paris, France; Faculté de médecine Pierre-et-Marie-Curie, université Paris VI, 4, rue de la Chine, 75020 Paris, France
| | - É Daraï
- Faculté de médecine Pierre-et-Marie-Curie, université Paris VI, 4, rue de la Chine, 75020 Paris, France; Service de gynécologie obstétrique, hôpital Tenon, hôpitaux universitaires Est parisien, 4, rue de la Chine, 75020 Paris, France
| | - J-P Lefranc
- Faculté de médecine Pierre-et-Marie-Curie, université Paris VI, 4, rue de la Chine, 75020 Paris, France; Service de chirurgie gynécologique et mammaire, hôpital Pitié-Salpêtrière, groupe hospitalier La Pitié-Salpêtrière-Charles-Foix, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - L Monnier
- Service d'oncologie radiothérapie, hôpital Tenon, hôpitaux universitaires Est parisien, 4, rue de la Chine, 75020 Paris, France; Faculté de médecine Pierre-et-Marie-Curie, université Paris VI, 4, rue de la Chine, 75020 Paris, France
| | - M Schlienger
- Service d'oncologie radiothérapie, hôpital Tenon, hôpitaux universitaires Est parisien, 4, rue de la Chine, 75020 Paris, France; Faculté de médecine Pierre-et-Marie-Curie, université Paris VI, 4, rue de la Chine, 75020 Paris, France
| | - F Huguet
- Service d'oncologie radiothérapie, hôpital Tenon, hôpitaux universitaires Est parisien, 4, rue de la Chine, 75020 Paris, France; Faculté de médecine Pierre-et-Marie-Curie, université Paris VI, 4, rue de la Chine, 75020 Paris, France.
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Adjuvant hysterectomy for treatment of residual disease in patients with cervical cancer treated with radiation therapy. Br J Cancer 2008; 99:1216-20. [PMID: 18854823 PMCID: PMC2570512 DOI: 10.1038/sj.bjc.6604619] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The objective of this retrospective study was to determine the efficacy of adjuvant hysterectomy for treatment of residual disease in cervical carcinoma treated with radiation therapy. Between 1971 and 1996, 1590 patients with carcinoma of the uterine cervix (stages I-IIIb) were treated with radiation therapy. Three months after completion of radiation therapy, the status of local control was investigated, and total abdominal hysterectomy was performed in cases in which central residual disease existed in the cervix. Of the 1590 patients, residual disease was identified in 162 patients. Among these patients, 35 showed an absence of distant metastasis or lateral parametrial invasion and underwent hysterectomy. The overall 5- and 10-year survival rates for these patients were 68.6 and 65.7%, respectively. There was no significant difference in survival between patients with squamous cell carcinoma and those with non-squamous cell carcinoma or between patients with stage I/II carcinoma and those with stage III carcinoma. With respect to treatment-related morbidity, five (14.3%) patients suffered grade III or IV complications after hysterectomy. Adjuvant hysterectomy is an effective addition to radiation therapy in the treatment of cervical cancer, even in patients with stage III disease and in those with non-squamous cell carcinoma.
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Turrini O, Guiramand J, Moutardier V, Viret F, Mokart D, Madroszyk A, Lelong B, Bège T, Blache JL, Houvenaeghel G, Delpero JR. Perineal small bowel fistula after pelvic exenteration for cancer: technical guidelines for perineal fistula. Ann Surg Oncol 2006; 13:1622-6. [PMID: 16983591 DOI: 10.1245/s10434-006-9117-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Revised: 05/26/2006] [Accepted: 06/05/2006] [Indexed: 12/20/2022]
Abstract
BACKGROUND To determine guidelines for the management of perineal small bowel fistula (PSF) after total or posterior pelvic exenteration. METHODS During 15 years, 315 curative pelvic exenterations were performed. PSF occurred in 15 patients (3.5%). We retrieved the precise modality of radiotherapy (fields and doses) and management of all patients (type of surgery, number of surgery and mortality). Delay of occurrence was divided in early (within 30 days or before hospital discharge) and delayed. RESULTS All patients underwent surgery. Mortality rate was 13%. Fourteen patients (93%) had history of radiotherapy. No PSF was noted after anterior pelvic exenteration. Higher frequency of PSF was noted after total pelvic exenteration versus posterior pelvic exenteration (P = 0.04). Early PSF occurred in four patients (27%) with higher frequency of small bowel intraoperative injury. Late PSF occurred in 11 patients (73%) divided in small bowel injury in contact with pelvic staples (n = 4) and disease recurrence (n = 6, local recurrence or carcinomatosis). One patient had delayed PSF by ulceration of small bowel in contact with pelvic drain. CONCLUSION PSF was a life-threatening complication of pelvic exenteration. Radiotherapy leads to weaken small bowel with difficulty of cicatrisation. During pelvic exenteration: (a) extreme careful dissection and interposition of great omentum could avoid small bowel injury, (b) control of pelvic vessels and closure of rectum remnant should not used staplers. Intraoperative management of PSF used successful simple repair in case of early PSF or segmentary resection indeed enlarged to right colon in case of delayed PSF. Postoperative courses had to use intravenous hyperalimentation and digestive tract discharge.
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Affiliation(s)
- Olivier Turrini
- Department of Surgical Oncology, Institut Paoli-Calmettes and Université de la Méditerranée, 232 Bd de Sainte Marguerite, 13009, Marseille, France.
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Houvenaeghel G, Lelievre L, Rigouard AL, Buttarelli M, Jacquemier J, Viens P, Gonzague-Casabianca L. Residual pelvic lymph node involvement after concomitant chemoradiation for locally advanced cervical cancer. Gynecol Oncol 2006; 102:74-9. [PMID: 16406062 DOI: 10.1016/j.ygyno.2005.11.037] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2005] [Revised: 11/10/2005] [Accepted: 11/18/2005] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Concomitant chemoradiation (and brachytherapy) has become the standard treatment for locally advanced cervical cancers (FIGO stage IB2 to IVA). Adjuvant surgery is optional. The aim of this study was to evaluate the rate of residual positive pelvic lymph nodes after chemoradiation. METHODS From February 1988 to August 2004, 113 patients with locally advanced cervical cancer have been treated by chemoradiation followed by an adjuvant surgery with a pelvic lymphadenectomy performed (study group). A para-aortic lymphadenectomy had also been performed in 85 of them. RESULTS The mean age of the patients was 48.4 years (27-74). FIGO stage was: IB2 in 17.7% (20/113), II in 44.2% (50/113), III in 21.2% (24/113) and IVA in 16.8% of the patients (19/113). The mean number of removed nodes was 11.5 (median 11) in pelvic, and 7.5 (median 7) in para-aortic basins. A pelvic lymph node involvement was present in 15.9% (18/113) of the patients after chemoradiation. In 11 patients, only one node was positive. 11.7% (10/85) of the patients had a para-aortic lymph node involvement. A residual pelvic lymph node disease has been observed in 6.3% (4/63) of the cases with no residual cervical disease (or microscopic) versus 26.5% (13/49) of the cases with macroscopic residual cervical tumor (P = 0.003). CONCLUSIONS Our experience shows that a pelvic lymph node involvement persists in about 16% of the patients after chemoradiation. We can make the assumption that performing a pelvic lymphadenectomy along with the removal of the primary tumor after chemoradiation could reduce the rate of latero-pelvic recurrences, whatever the para-aortic lymph node status.
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Affiliation(s)
- Gilles Houvenaeghel
- Department of Surgery, Institut Paoli-Calmettes, 232 Bd Sainte Marguerite, 13009 Marseille, France
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Dreyer G, Snyman LC, Mouton A, Lindeque BG. Management of recurrent cervical cancer. Best Pract Res Clin Obstet Gynaecol 2005; 19:631-44. [PMID: 16150396 DOI: 10.1016/j.bpobgyn.2005.03.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Treatment for cervical cancer is very successful, especially in early stages. However, most patients presenting in late stages of disease will experience recurrence. The prognosis of recurrent disease is very poor and treatment options are limited. The diagnosis of recurrence may be apparent or difficult, but determining the extent of disease is always complex. Routine follow-up of asymptomatic patients has other objectives and is not a reliable way to detect recurrences. Symptomatic patients require extensive investigation to detect the extent of the disease. For patients with central pelvic recurrences, exenteration offers the prospect of survival in more than one-third of cases. Newer developments include laterally extended endopelvic resection that may become an option for patients with more extensive pelvic recurrence. For patients with recurrences of cervical cancer, the roles of second-time radiotherapy or postradiation chemotherapy are very limited. Palliative treatment is important for all patients with untreatable disease. Pain relief forms a central part of palliative care. Caregivers also experience emotional feelings and probably function best in a system offering strong colleageal support.
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Affiliation(s)
- G Dreyer
- Gynaecologic Oncology Unit, Department of Obstetrics and Gynaecology, University of Pretoria, P.O. Box 667, Pretoria 0001, South Africa
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